This blog chronicles my travels as a 2016-2017 Thomas J. Watson Fellow exploring cultural attitudes towards health technology around the world. Starting from and returning to New York City, USA, I am traveling to Sweden, Qatar, India, Singapore, Japan, and Botswana over the course of one year.

Category: Project (health)

Peek Vision is a health startup aimed at improving access to vision services and eye care. Their main product is the Peek Acuity mHealth solution, a smartphone app that allows anyone to conduct a vision screening in a few minutes. They have a few other products as well, all of which contribute towards their goal to perform vision screenings (particularly for schoolchildren) as well as make a real impact by providing eye care and/or glasses for those who need them.

Peek was founded by a London-based PhD candidate, piloted in Kenya, and has had a chapter in Botswana for a couple years (here is a great TED Talk by Peek’s founder). Last year, Peek partnered with the Botswana government to perform screenings in 49 schools, rural and urban, in the country’s Good Hope district.

I interviewed Maipelo, the project manager of Peek Botswana, to learn more about the screenings. She traveled to many of the schools involved throughout the screening process and personally helped train local healthcare workers so that they could use the app.

A typical visual acuity “tumbling E” board.

Since the app is free, I downloaded it myself. The app acts as a replacement for the “tumbling E” boards typically used in visual acuity tests – children are supposed to tell screeners which way the “E” is pointing (for example, an “E” in the usual orientation is pointing to the right; a backwards “E” points to the left). The typical boards can get lost or damaged, and the pattern of Es can be memorized by children (a sequence of up, right, down, etc). The Peek app addresses those problems while also keeping track of anyone who fails the test for follow-up purposes.

Maipelo with the Peek Acuity app.

When you first open the app, it brings you through a tutorial to show how the screening should go. The screener needs to stand exactly two meters from the student (or whoever will be screened), holding the phone so that the screen faces the student at eye level.

My favorite part about the Peek Acuity app is how the actual screening goes – the screener never needs to look at the app while the student is watching the screen. When an E is displayed on the screen, the student points in the direction of the E. The screener then swipes the phone screen in the direction that the student is pointing and never needs to look at the E. The screener doesn’t need to know if the student gave the correct answer; it is automatically recorded by the app. The Es displayed on the screen continue to change direction and size, adjusting to the student’s performance. If the student can’t see the E well enough to guess, the screener is supposed to shake the phone so that a new, slightly larger E appears.

Screenshots from the app tutorial.

After about two minutes, the phone plays a sound to indicate the end of the screening. The screener then looks at the phone and sees the result (for example, “0.8” for a student with quite poor vision). There’s also a built-in simulator that displays how blurry a chalkboard would look to someone with 0.8 vision, for example, so that the screener truly understands the numerical result. The simulator feature also ideally builds empathy for students who have had undetected vision impairments – students who struggle in school and often get written off as being lazy or naughty by teachers who assume that they can see perfectly fine. (This is true for hearing as well. The HearScreen people in Pretoria described hearing problems as a “silent epidemic” because kids with such impairments often go undetected and are treated like bad students when they don’t do well in school).

A screenshot from the app showing the vision simulation feature.

Maipelo told me that, for the most part, the screeners and the students responded well to the Peek screening. Everyone is excited when they see the app, she said; less so when they are told to use it and realize they have work to do. Regardless of how fast and easy the screening process is, it’s still work, especially when screeners work all day long checking hundreds of schoolchildren. Also, Maipelo said, those who were less comfortable with the phones would take longer to input data. Even if the difference is a minute and a half instead of, say, 45 seconds, that adds up with so many screenings per day – and it can get frustrating for the less tech-savvy screeners.

I also asked Maipelo about the follow-up process. When Peek Acuity indicates that a child has impaired vision, the app prompts the screener to enter their contact information. The app then automatically texts the child’s parents with the follow-up details – where they should go to meet with an eye doctor and when. That’s when the children would get glasses if they needed them.

One of the Peek Botswana employees demonstrates a screening with the Peek Acuity app.

That is where it could get complicated, Maipelo told me. Even though all the parents had a positive reaction to the idea of medical technology, she said, they never liked to hear that their kids had an impairment and needed a follow-up. People only question the technology after it illustrates a problem, she said. Even if the app just says that their child needs glasses, parents immediately respond negatively to anything they interpret as a “medical issue.” Maipelo said that some people believe such problems are curses or bewitchments. “Bewitchments?” I echoed. Yes, she said, people grow up hearing about witches.

This isn’t the first time I’ve heard about witches in Botswana. It seems to be a traditional idea that witches are afoot, causing problems or punishing people for various reasons in various ways. I think when there is a lack of awareness about these things – not knowing how common and remediable vision impairments are, for example – all medical problems could seem as serious as a witches’ curse.

Another local later told me that some people in Botswana have the misconception that glasses will actually worsen vision. If a well-sighted person looks through someone else’s prescription glasses, of course the view is distorted; this apparently leads some well-sighted people to believe that glasses are harmful. Also, people with glasses never stop needing glasses, needing stronger prescriptions as time goes on. Both glasses and crutches are medical devices, but crutches help you get to a point where you don’t need crutches any more; glasses stay forever. Apparently this, too, contributes to the misconception that glasses degrade vision. Of course, most people in Botswana do know that glasses help, but of course it would be best if everyone (especially the more skeptical parents) were on board.

Another interviewee phrased it like this: “In our culture, everything should be normal.” Everything should fit the status quo. People don’t accept the abnormal; they say it’s the work of witches, he said. (And there they are again). Unfortunately many impairments, including poor vision, aren’t normalized, so everything (even the need for glasses) gets labeled as “abnormal.” I’ve heard this in general, too – many people have told me that fitting in and maintaining the status quo is very important in Botswana, which I think makes sense with the neighborhood lifestyle here. In terms of medical problems, it all boils down to awareness and the importance of normalization. If more people wore glasses and it was seen as normal, there would be less stigma against vision impairments, and it would be easier to convince people to treat vision problems less like serious, scary medical issues.

I’ve really enjoyed getting to know Peek Vision throughout my time in Botswana. Including my interview with Maipelo, I’ve had many interactions with Peek – I’ve talked to people involved in different aspects of the company; I sat in on a government meeting where Peek pitched a budget to the Ministry of Health for a potential national rollout; and I’ve met health workers who participated in Peek screenings in very rural areas. When I started my project, almost all of my meetings were one-offs. I had hourlong chats about many different devices and technologies, definitely seeing more breadth than depth. There haven’t been so many examples of medical technology to explore in Botswana, so I’ve tried to dig deeper into the examples that are here, and it’s been cool getting to see Peek Vision from different sides. These diverse vantage points have also illustrated different challenges of getting an mHealth project underway in Botswana – such as how important hierarchy and social niceties are when dealing with government officials in the capital city, or how screeners in rural areas don’t think about how easy or difficult the app is to use if they’re not getting paid to do the screenings. I’m really grateful to Peek Vision for all that they’ve shown me here in Botswana.

This is Peek’s hardware product, Peek Retina. It wasn’t part of the school screenings, so it’s hard to talk about user responses, but I think it’s very cool. It’s a small device that can fitted over a smartphone camera for retinal screening, which can detect diabetic retinopathy and other issues.I had my pupil dilated to be the guinea pig in a hands-on Peek Retina demonstration. Here, someone is trying to screen my retina with the Peek device and a smartphone, with an optometrist looking on.Always a fan of cool hardware!

As the drizzle started to fall on me in Pretoria, I thought about how neither I nor the rain was supposed to be there. I had ten days left on the Watson (six, now), and I had decided to go to Pretoria, South Africa, to meet a company there for my project. It’s winter in South Africa at this time of year, and in the northeast, where the capital of Pretoria is, that means dry season; rain is only supposed to fall there in the summer.

This is at a day care center in Mamelodi, ZA. I’m standing here with Charles, who helped HearX organize screenings for the children.

I wasn’t supposed to be in Pretoria because South Africa is not one of my Watson project countries. Beyond that, I’m technically not supposed to go there because I’ve already spent so time in South Africa, having studied abroad in Cape Town for 5 months my junior year of college. But Pretoria is on the other side of the country, far closer to Gaborone than to Cape Town, and I figured it would be worth breaking the rules for just a few days to see something relevant to my project (especially since I’ve nearly exhausted my project opportunities in Botswana by this point).

The Voortrekker Monument of Pretoria. The monument and enclosed museum commemorate the Voortrekkers, pastoralists who traveled across South Africa in the “Great Trek” of the 19th century.At the Voortrekker monument.

I arrived back in Gaborone last night after another 6-hour bus ride across the Botswana-South African border. Earlier in the Watson, I would have asked for permission ahead of time for this short weekend transgression. As I was visiting a monument in Pretoria enjoying the rain, weather I hadn’t felt in a long time, I realized that I had reached a new level of confidence – the confidence to make that judgement call and know, on my own, that it was still within the spirit of the Watson and still good for my project to break the rules just a little bit – a level of confidence that I could only have now, at the end of the Watson. You can only properly bend the rules once you’ve lived within them and respected their existence.

On the steps of the Voortrekker monument.Looking down from the top floor of the monument.

Of course I have been making my own decisions all year, but always within the bounds of what had already been approved for me – going to Pretoria was a decision that I made on my own basis of what was appropriate, confident that it would be worth it. I used to think “confidence” was simply being comfortable in yourself and your abilities. But that sort of confidence is so easily confused with arrogance. There’s a deeper confidence, I’ve found, that lies within the humble acceptance that you’re making it up as you go, that there is a lot to learn, and that you can still deal with everything in life anyway. The confidence of knowing yourself and having that be enough – not needing anyone or anything else to move forward. The confidence to be able to talk to anyone and not be better than anyone else.

I wasn’t too interested by the museum in the Voortrekker monument, but I loved the architecture of the building and all these vantage points that led to geometric views.

Anyway, before this gets any sappier, I’m glad I went. My project contacts in Gaborone were the ones to suggest the trip to meet with HearX, an e-health start-up that spun out of the University of Pretoria. HearX’s main product is HearScreen, a mobile health solution that facilitates simple hearing screenings. With the HearScreen app and approved headphones, the screener plays 3 different tones in each of the listener’s ears. The listener is supposed to raise a hand when they hear a sound, and the screener notes whether or not the listener responds to all the tones played. At the end of the two-minute screening, the app alerts the screener if the listener has a hearing issue and needs to be referred to an audiologist. The audiologist can then determine why the listener failed the screening (HearX told me that the most common cause is wax blockage, a simple problem to fix) and if they need to go to the next step, such as receiving a hearing aid.

Lelanie (left) and Charles (right) at the Mamelodi day care center. Charles is holding the HearX case, which includes everything needed for a screening – mainly a smartphone with the HearScreen app along with the specific headphones.

I met the HearX people at the Innovation Hub, a set of offices for start-ups in Pretoria. From there, I went with Lelanie, a social worker at HearX, to Mamelodi, a nearby township. That’s where we visited the day care center and met with Charles, a local contact who has helped HearX do school screenings for children in the area. Charles brought in a young boy to show us how the screening worked, and he explained everything to the boy in his local language. I find that these “local ambassadors” are often key for encouraging the adoption and use of m-health and e-health products; Charles is clearly great with kids and made an effort to make the little boy feel comfortable. Lelanie also told me that the kids get more excited about the hearing screening when the screeners tell them that they have to wear the big headphones “like a DJ.”

Charles had me act as the screener for this trial run. The app was really easy to use, although I think I went through the screening a bit too quickly!

I sat behind the kid we were screening so that he wouldn’t be influenced by my actions. Lelanie and Charles told me that when the HearScreen project started, they realized that kids could just watch the screeners using the app, raising their hands when they saw the screeners tapping the phone – anticipating the tone rather than actually responding to it. Otherwise, they haven’t had any issues. HearX is planning to expand into Botswana, which I think would be great. The main challenge there, as I’ve mentioned earlier, is that they’ll have to integrate with the Botswana government to an extent that they don’t have to with the South African government.

I went to the offices of the “Botswana Innovation Hub” to meet with Deaftronics, the only local medical device start-up I’ve found in Botswana. Deaftronics makes the “Solar Ear” unit, a solar-powered charger for hearing aids. The small, handheld device has a solar panel and a port for a digital hearing aid as well as ports for rechargeable hearing aid batteries. In 3 hours of sun exposure, the unit can fully charge the batteries, which can be used for up to a week without needing to be charged again.

The Solar Ear unit with space for a standard hearing aid and two rechargeable hearing aid batteries.

Deaftronics’s mission is to provide hearing aids to all hearing-impaired people who need them, including people living in remote areas without consistent access to electricity. They emphasize empowerment of the deaf community not just by providing solar-powered hearing aids, but also by training and employing deaf people in their manufacturing and design processes.

Tendekayi Katsiga, the technical director of Deaftronics, is a firm proponent of co-design (participatory, user-based design) and believes that the best solutions come from the users. He told me that the idea of solar-powered hearing aids came from a school for the deaf in Botswana and that his role as the electronics engineer was to transform that idea into a product. For any sustainable project, he said, the process of “iteration and ideation” is key – improving upon the design of a product multiple times until it is exactly what the end users need and want.

Tendekayi Katsiga with the device (the hearing aid is inserted for charging here).

In addition to the benefits of co-design, combating stigma is a great reason to employ deaf people, said Tendekayi. There is a stigma that hearing-impaired people cannot work or be productive, and Tendekayi believes that it’s important to highlight that the opposite is true – hearing-impaired people might even be more productive than the average hearing employee, he said, because they can focus on the work with fewer distractions. (It’s certainly a controversial idea, but an interesting change from the usual underestimation of the abilities of hearing-impaired people. I couldn’t find a ton of backing for this, but this book and some other articles support the idea).

Tendekayi mentioned that a challenge of selling the Solar Ear in Botswana is that the government can afford hearing aids and batteries for the few hearing-impaired members of its small population. Very few people would opt to purchase a private product when they can get something from the government for free – and since the government is such a large force in Botswana, it is hard to be a private business there. This moment reminded me of the health worker’s complaint in Sekhutlane that the government spoon-feeds its citizens too much. He believed that if Botswana’s government didn’t provide so many services for free, more people would be motivated to work as well as spend money, thus stimulating the economy.

Thus while some people are using the Solar Ear unit in Botswana, Deaftronics is focusing on potential users in places where it can have more impact: Zimbabwe, Zambia, Mozambique, and other areas in sub-Saharan Africa where hearing-impaired people cannot get aids from their governments or purchase more expensive options. Deaftronics has been endorsed by UNICEF, which could pave a pathway for providing Solar Ear units for free in such areas. In future designs, Deaftronics hopes to add a USB port to its Solar Ear unit so that users can also charge their cellphones via the device.

Entrance to the Botswana Innovation Hub.

When I asked him why Deaftronics seems to be the only medical device start-up in Botswana, Tendekayi told me about another complicating local factor: the people of Botswana don’t believe in Botswana-made products. I’ve heard this a few times now, and it’s taught me the importance of local inspiration. Almost everything used in Botswana is imported from South Africa or further abroad. Botswana’s population is small; no great innovations, products, or companies have originated in the country. Of course, that doesn’t mean that great things cannot come from Botswana, but it isn’t exactly inspiring for Botswana’s citizens.

In America, we grow up with incredible success stories of companies like Ford Motors and Facebook as well as examples of revered entrepreneurs and so-called visionaries. These stories inspire generation after generation to keep building, to keep dreaming, and to keep trying, even after many failures. Part of this is due to the large population of the US; if there is a large enough number of start-ups, even if each has a very low chance of success, some of them will make it big. Representation matters: it’s hard to be inspired to make something in your country if there are no success stories to look up to.

I’ve heard this from a few Batswana now, and Tendekayi phrased it well – there’s a perception that when a product is home-grown or designed locally, it’s not the “real thing.” Now that Deaftronics has won a few awards, Tendekayi is confident that the perception will change. Especially with the establishment of the Botswana Innovation Hub, Tendekayi hopes that more Batswana will be inspired to innovate locally.

A rendering of the soon-to-be “Botswana Innovation Hub” – the space is moving to a completely new location to serve as a true hub for budding companies in Gaborone. (From this article).

We stopped at the Tropic of Capricorn on the way back from Serowe. Serowe is a small town in Botswana, and I traveled with a group to visit the hospital’s vision center there and learn about the process of eyeglass making. The Tropic of Capricorn is a latitude in the Southern Hemisphere, and it traces the southernmost circle on Earth where the sun’s rays can hit from directly overhead (any further south, they always hit at an angle). The northern equivalent is the Tropic of Cancer.

A Capricorn myself, though not a big astrology person, I was pretty excited to be there. It’s marked by a simple street sign and a small monument – a rock with a vertical metal rod on top. Every year, at 12:12pm on the winter solstice (December 22; summer in this hemisphere), the sun shines directly down onto the rod. The light beams straight through the hollow rod and onto the rock, creating no shadow. Since we weren’t there at the solstice, of course, the rod cast a shadow.

Here is the rod with a description on the rock below.

That morning, we had visited the Vision Centre, an area of the eye health ward in Serowe’s hospital. Equipped and funded by a British charity organization, the Vision Centre includes all the facilities necessary for cutting glass lenses to make custom eyeglasses. That’s where we met Michael, a technician who makes 10-15 pairs of glasses a day. He walked us through the process of cutting a lens, showing us the 5 or so machines involved.

This is Michael, about to cut the circular glass lens he holds in his hands. The many machines he uses to do so are behind him.A wheelchair in the Serowe hospital fashioned out of a plastic lawn chair and common bicycle tires. A worn-off sticker shows that they were donated by some charity or NGO (perhaps American?) but it’s too faded to read the name.The foyer of the hospital.

In Serowe, and every time I’ve been somewhere new, we did multiple rounds of introductions and hellos. Every day, I think about how important social norms are in Botswana. I think I’ve touched on this before – there is a well-established code of social interaction here, something like that small-town friendliness in suburban America. It’s at the same time my favorite and least favorite thing about Botswana. Everyone says hello (dumelang!) to each other on the street, even strangers, often continuing to ask “How are you?” and the like. It’s considered very rude to begin any interaction, even if you’re just purchasing stamps at the post office, without these pleasantries. I think it’s lovely, and in a capital as small as Gaborone, it’s important to be kind to people when you might be speaking to your brother’s neighbor or your friend’s mother. As a result, the Batswana seem far more socially adept than many people I know.

If spaces could talk…what would they say? I see this almost every day in Main Mall, Gaborone.

At the same time, it drives me crazy. It slows things down. No one is ever in a hurry – to appear so would be rude. I grew up in Manhattan, where I perfected the style of speed-walking that signals “don’t talk to me.” It’s also a safety thing. Every time a random man or cab driver or stall owner calls “Hello” to me on the street, I’m conflicted between respecting Batswana culture and wanting to ignore it, as I’ve been trained to ignore any attention from random male passers-by. Usually I respond with a curt “Hello” in return and promptly ignore any ensuing conversation. On longer walks, I listen to podcasts or music, and hope that the earbuds serve as a defense against being rude – I smile at the people around me while conveniently being unable to hear them.

More street art from Main Mall.A traditional Botswana meal from the food vendors seen in the background. For 15 pula ($1.50), you can get this little plate with your choice of starch, meat (seswaa is traditional – pounded beef), and veggie sides (I like the sauteed greens and mashed butternut).

Anyway, I’m off to Victoria Falls tomorrow, which I’m excited for since it’s considered one of the 7 natural wonders of the world. I’m hesitant as well because it will be a very touristy weekend, outside of Botswana, with other American travelers – none of that is very Watson-y. But it’s only a two-day trip, and I missed the opportunity once before (I could have gone when I was studying abroad in South Africa for 5 months), so I didn’t want to miss it again. I’m also feeling quite good about my project here. I’ve met with a few different groups by now, and a couple days ago I met with the only local medical device start-up in Botswana, so that was great. Plus, it’s been too long since I’ve taken a flight! (well, a couple months).

Food vendors by the side of the road for watermelon, nuts, and crunchy worms (lower left).Advertising in Gaborone.The flower wall at Sanita’s Tea Garden, a plant nursery and café in Gaborone.More from Sanita’s.

There’s not much to do in Sekhutlane, but we had some fun at this bakery.

Last week, I had the opportunity to visit the remote village of Sekhutlane (pronounced something like ‘Sek-qui-kla-nay’), a 5 hour’s drive from Gaborone. I was there with some members of BUP, the University of Botswana – UPenn Partnership, to meet government healthcare workers who had participated in a mobile health program to perform vision screenings on schoolchildren using a smartphone app (called “Peek Acuity;” more on that in another post).

On the way to Sekhutlane.A welcome sight after waking up at 5:00am in Gaborone!

Sekhutlane is a village of about 700 people, and most people seem to farm or work in government-sponsored volunteering positions that provide food and water. There are hardly any shops, and the closest upper high school is in the next village, 70km away. Since the main mode of transport in Sekhutlane is a donkey-drawn cart, 70km is a prohibitive distance for most.

Sekhutlane.This is the car we took to get to the village. Four-wheel drive is a must; our last hour on the way to the village was along a bumpy dirt road.It’s pretty common to hire drivers for these sorts of trips and pay them in cash for their driving and the gas.The only shop in the village is a small shack of corrugated steel where you can buy basic items over the counter.

We hadn’t brought any lunch, and the only place to get ready-made food in the village is a small bakery that makes simple rolls and loaves in an outdoor oven. The bread was warm, soft, and delicious after such a long car ride. We learned from the healthcare workers, Kenewe and Kagiso, that the villagers eat canned food most of the time, especially canned beef and fish. Kenewe and Kagiso are not from Sekhutlane originally – the government assigned them there to work for two years. They are both far from home and hope to get reassigned to a less remote location in the future.

One of the BUP team members enjoys a freshly-baked roll in front of the bakery’s oven.Kenewe (left) and Kagiso (right). They were so lovely to talk to.

Though we were there to learn more about a mobile health endeavor, the challenges in Sekhutlane rarely involve technology. There are vision problems in the village, often due to the dust, but the more pressing issues are HIV/AIDS management and teenage pregnancy. Kagiso said that, since junior high is the highest level of school in the village, many of them finish school at 15 and become parents. They don’t know what else to do, he said, especially since they aren’t exposed to a range of possible professions they might aspire to. Kagiso is also frustrated with the way the government “spoon-feeds” the villagers, providing them food and even housing for minimal work – he wishes the government would instead incentivize them to become self-sustainable in some way.

A home in Sekhutlane.

The president of Botswana is experiencing a bit of backlash right now for a recent visit to Sweden, where he discussed Botswana’s military policy and its “need” for an air force. A few people I’ve met, including the healthcare workers in Sekhutlane, are frustrated that the president is talking about war in such a peaceful country. Instead, they say, he could be focused on bringing health and education to all areas of the country.

A man on his way out of Sekhutlane.

We arrived on Sekhutlane’s “ARV Day” – the healthcare workers devote one day each week to providing the villagers with the newest stock of antiretroviral drugs for HIV/AIDS treatment – so the clinic was quite busy. Kagiso and Kenewe told us that HIV is so common, and the village so small, that they can usually figure out which villager is responsible for a new case. They said that since HIV/AIDS is so out in the open in Sekhutlane, there’s very little stigma about it there, and people feel comfortable talking about their partners and the disease.

The clinic of Sekhutlane. Check out the spots on that goat!

When I was in Lobatse, someone said that a main contributing factor to the high rate of HIV/AIDS in Botswana is an attitude here of “I am my own boss.” I suppose it’s the flip-side – the lack of a common collective attitude – that is the real culprit, a mindset that doesn’t encourage thinking about how your actions affect others. Kagiso and Kenewe also happened to mention this individualism with regards to other issues in the village. Kenewe talked about a time she once tried to help a young child at school by providing him with new clothes. The other parents became jealous and angry with Kenewe, and they stole the clothes off of the child to put on their own children. She gave up after that.

Sekhutlane.

Another example of this thinking came up in our discussion about the vision screening, the initial reason we went to Sekhutlane. As a result of the screening, two children were diagnosed with vision problems, and their parents needed to bring them to a specific site on a specific day to receive glasses. Only one family had the means to do this, so only one of the two children actually got their glasses. “Why couldn’t that family take the other child, too?” I asked. “You only take care of your own here,” said Kenewe. That’s the attitude: fierce independence, even to the disadvantage of other community members. I’m not sure what caused this “I am my own boss” culture, but it’s been fascinating to hear it come up in so many discussions about health here.

Overall, it was great to see Sekhutlane and understand rural Botswana as a contrast to Gaborone.

A donkey cart in Sekhutlane.The most water and green I’ve seen since arriving in Botswana! Apparently this is South Africa, though, on the other side of the river.

Last week, I visited the Botswana chapter of the South African Federation for the Disabled, SAFOD. SAFOD is an organization that supports disabled people in 10 countries in southern Africa, and the Botswana chapter is called BOFOD. They are currently working on the “AT-Info-Map,” a three-year project to develop a smartphone app with information about all the assistive technologies (AT) available in the country. It will be released to Batswana users in a year or two and ultimately made available in the other member countries as well (Angola, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe).

Mr. Kayange (left) holds a smartphone with the latest version of the AT-Info-Map app. To the right is Mr. Chiwaula, Director General of SAFOD.

I met with Mr. Chiwaula and Mr. Kayange at the BOFOD office in Gaborone to learn more about AT-Info-Map. The app, aimed towards disabled people and their caretakers or other stakeholders, will inform users of the location, availability, and cost of the assistive technologies they seek. Assistive tech, AT, includes hearing aids and wheelchairs, as well as tools not often thought of as technologies such as crutches, prosthetics, and glasses.

Mr. Kayange told me that all assistive technology in Botswana is imported from South Africa, Europe, and other areas – there are no local manufacturers. Thus the AT suppliers in Botswana sometimes have minimum order numbers that make it unfeasible for one person to get just one or two crutches, for example. Even though the government would supply those low quantities for free, said Mr. Kayange, the demand is still higher than the government’s supply, and some people still need to purchase their own assistive devices. He said that, as it is, the only people who know where to find reliable assistive technologies are wealthy people with expat connections – people who can order specific devices from abroad if need be. At least with the app, anyone with a smartphone could access the same information.

(Of course, I asked them what happens if people in their target user group don’t have smartphones. They agreed that this is a potential problem – it’s unrealistic to assume that everyone has a smartphone, which SAFOD discussed. They decided that it wasn’t enough of a reason not to make the app; those that do have smartphones will still benefit).

A close-up of the app’s home page. Clicking “Start” opens another simple page that allows the user to search for assistive technologies in their region or by category.

A lot of our conversation centered around the issues of access and awareness – words that came up many times during my time in India. Especially in Botswana, where the population is so sparse, people may live very far away from a hospital or clinic (an access problem) and may have no idea what AT might be relevant to their needs, let alone where to get it (an awareness problem). Mr. Kayange and Mr. Chiwaula told me that the government’s idea of AT is essentially just wheelchairs and crutches. If nothing else, AT-Info-Map could inform people of other types of AT, ultimately increasing demand for better services. The AT-Info-Map app will store usage data such as the most-commonly-searched-for assistive technology, and if that data demonstrates an unaddressed need (for prosthetics, for example), SAFOD could take that data to the ministries and advocate for more government-funded prosthetics.

Without engaging the government, said Mr. Kayange and Mr. Chiwaula, they can’t be successful. In Botswana, probably because the country is so small and centralized, the government is involved in all health endeavors – so it’s crucial to partner with them if a project is going to be sustainable. However, like in most countries, this involves dealing with a lot of slow bureaucracy and government officials who are very cautious about new ideas.

There’s not as much “activity on the ground” as BOFOD would hope, and the status quo for disabled people largely stays the same year after year. Mr. Chiwaula pointed out that, as Botswana is a relatively stable and well-off Southern African country, it’s not a popular recipient of donations. Since international organizations tend to focus their resources on the neediest places, Botswana’s economic advantage has become a disadvantage – because, as Mr. Chiwaula was saying, such donations would still be welcome. This made a lot of sense to me, though it was sad to hear.

SAFOD was able to build the AT-Info-Map by collaborating with Washington University in the US for technology support, the international organization Dimagi for the mobile app design, and AfriNEAD, a network for disability research. Throughout the design process, SAFOD has also consulted with professionals, government officials in the Ministries of Health and Education and the President’s Office, and potential users. They went back and forth with potential users, performing user-centered design by returning to the field with multiple prototypes. Now, they are satisfied with the version they have and will begin deploying the app for use. Mr. Kayange and Mr. Chiwaula told me that their current concerns at the moment are how to get people to use the app once it’s available, as well as how to incentivize AT suppliers and service providers to register their information on the app. I was glad to hear that their final design is the result of several rounds of user feedback – hopefully that’s enough to guarantee a positive response on a more national scale. It will be interesting to see if the availability of AT in Botswana changes at all in the next few years once this app is in use.

Things have been going on faster than I can write about them – my handwritten notes are starting to pile up! – so I wanted to do a quick catch-up. I really feel like time is flying by now, mostly because of end-of-Watson pressure, but also because there’s more going on in Botswana than I thought.

At the University of Botswana, which has a beautiful campus.

I’ve already had a few project meetings, and there are some very cool mHealth (mobile health) endeavors here. Many of these projects come from the University of Botswana, which has a campus in Gaborone and a partnership with UPenn back in the US. From the Botswana-UPenn Partnership (BUP), I learned about TB-PEPFAR, their project to improve TB screening and testing in Botswana. One aim of the project is to provide community health workers (CHWs) with phones to collect data on TB patients. The phones use a mobile application called RedCap, which provides secure data capture for researchers and also allows CHWs to fill out digital forms rather than paper ones.

PEPFAR, or the US President’s Emergency Plan for Aids Relief, focuses on the diagnosis and treatment of TB because the infectious disease is so common in HIV patients – it was the cause of one-third of AIDS-related deaths in 2015 (source). This is particularly relevant here in Botswana, where the biggest public health crisis is HIV/AIDS (it is the leading cause of death, accounting for 32% of all deaths according to the CDC).

A week ago I traveled with a doctor of the TB-PEPFAR team to Lobatse, a small town an hour south of Gaborone. He was there to oversee a small conference for nurses and doctors from clinics in Lobatse and surrounding areas. As it turned out, the attending health workers were not users of the RedCap app – the conference was really a training session to update the health workers on the best methods for TB screening. Even though the training day wasn’t about entering data with RedCap, I was still curious to see if technology would come up in another way.

At the beginning of the training day, all the participants had to take a “pre-test.” Their scores get compared to the results of the “post-test” they take at the end of the training.

Also, I learned a lot about TB. I became interested in medtech via the technology, not the medicine, so I still have a lot to learn about basic medical topics. During my stay in Lobatse, I learned about the importance of ‘sputum’ for TB diagnosis (I had never heard that word before, but sputum is the name for the mucus-y fluid that you might cough up when you’re sick, and testing this sputum is essential to TB testing). I learned that alcohol, overcrowding, and HIV/AIDS all contribute to TB. I also learned that while sputum induction (SI) is one way to diagnose TB patients, there is another method, gastric aspiration (GA).

The day’s training included “how to”s for both methods, SI and GA. GA was the more complicated and time-consuming method presented, requiring more equipment than SI – including a nebulizer. The presenter of this section had a nebulizer on the table and began demonstrating how to use it. One of the conference organizers, sitting in the back, called out: “Is this the nebulizer you all have in your facilities?” Everyone shook their heads or said “no.” The presenter went on with the nebulizer demonstration, though it seemed obvious to me that everyone would prefer the SI method. He later told me that since there were so many stakeholders in this TB-PEPFAR project (including both the US and Botswana governments), it was difficult for them to change or skip slides from a pre-approved presentation.

The nebulizer demonstration.

One of the topics of conversation throughout the day was, of course, how to diagnose patients who have both HIV/AIDS and TB. The same organizer who asked about the nebulizer above told me that TB in HIV/AIDS patients manifests quite differently than TB alone. She said that it frustrates her when medical students from American universities come into Botswana and try to diagnose TB just based on the theory they’ve learned (without recognizing that in some cases, she said, HIV/AIDS patients with TB will test negative for TB). She said that it’s a feeling you have to develop about HIV/AIDS patients – whether they have TB or not – and treat for it even if there’s no conclusive evidence. I thought that was a fair frustration and a good example of why it’s important to know the medical particularities of a place before you treat, diagnose, or develop medical devices for various conditions.

Part of “How to Diagnose TB in Children.”

Finally, there was a moment where the nurses and doctors discussed what might contribute to Botswana’s high TB rates – the possible social, cultural, biological, and policy factors – and I wonder if these factors also affect medical device acceptance here. The interesting answers included: high HIV prevalence (of course); migration; non-adherence to policy; not enough people in healthcare management due to the small population; and the use of traditional medications and going to church instead of seeking immediate treatment at a hospital (I have noticed that religion is quite important here – more on that later).

At the beginning of this year, I would start with examples of individual devices and only focus on cultural factors once I could generalize trends across those conversations. Now I find myself approaching both at once, looking for those cultural trends right away so that I can keep them in mind as I encounter various medical technologies. I suppose it’s a good thing because it means that I’ve gotten faster at identifying the important factors for medical technology adoption – the “big picture” stuff – without needing so many small steps to get there. That said, I’m still looking forward to learning more about specific medical device and eHealth projects here!